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A 65-year-old man with metastatic cancer and past medical history of schizophrenia, developmental delay, and COPD was admitted to the hospital with a spinal fracture. He experienced postoperative complications and continued to require intermittent oxygen and BIPAP in the intensive care unit (ICU) to maintain oxygenation. Upon consultation with the palliative care team about goals of care, the patient with telephonic support of his long time caregiver, expressed his wish to go home and the palliative care team, discharge planner, and social services coordinated plans for transfer home. Altho

A 52-year-old woman with a known history of coronary artery disease and ischemic cardiomyopathy was admitted for presumed community-acquired pneumonia. The inpatient medicine team obtained a “curbside” cardiology consultation which concluded that the worsening left ventricular systolic functioning was in the setting of acute pulmonary edema. Two months post-discharge, a nuclear stress test was suggestive of infarction and a subsequent catheterization showed a 100% occlusion.

Institute for Healthcare Improvement. March 10. 2020.

The measurement of patient safety is a persistent challenge across the health care continuum. This webinar summarizes a set of 8 foundations to guide patient safety measurement improvement that include capitalizing data in real time and engaging patients in the measurement process. Speakers included Dr. Donald Berwick and Helen Haskell.

Institute for Healthcare Improvement. Principles for Improving Patient Safety Measurement. 

The measurement of patient safety is a persistent challenge across the health care continuum. This webinar will summarize a set of 8 foundations to guide patient safety measurement improvement that include capitalizing on data in real time and engaging patients in the measurement development process. Speakers will include Dr. Donald Berwick and Helen Haskell. The recording of the session is available until September 23, 2020.
Ward M, Shé ÉN, De Brún A, et al. BMC Med Edu. 2019;19:232.
“Serious games” are becoming more prevalent in health care. This article describes a "serious game" PlayDecide for use of multidisciplinary healthcare teams in which the teams are presented with real-world case stories of events and incidents, incorporating the perspectives of healthcare professionals and patients. Players are tasked with exchanging and discussing perspectives and information, then working towards a shared group policy position around error reporting and patient safety. This study evaluated the use of the PlayDecide framework in two large urban academic medical centers and noted a significant change in error reporting behavior among junior faculty post-intervention.